Security Issues in Psychiatric
of BQA 05-011 (PDF, 43 KB)
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Date: September 12, 2005 DSL-BQA
To: Hospitals HOSP 04
From: Otis Woods, Interim Director,
Bureau of Quality Assurance
DSL-BQA-98-005, dated January 26, 1998, was issued to remind hospitals
of their responsibilities to provide sufficient staffing levels and
adequate staff training in psychiatric treatment areas to deal effectively
with disruptive and aggressive patient behaviors. DSL-BQA 00-013, dated
January 6, 2000, responded to questions posed by hospitals and law
enforcement personnel and replaced DSL-BQA-98-005. This memo updates and
replaces DSL-BQA 00-013.
The routine presence of weapons in a psychiatric treatment facility,
including firearms, pepper agents (spray and foam), and electric restraint
devices (stun guns and tasers/tazers) is not acceptable. Such practice is
contrary to Wisconsin Administrative Code, section HFS 94.24(1), which
- Treatment facilities shall provide patients with a clean, safe and
The practice also violates section HFS 94.24(2), which states that:
- Staff shall take reasonable steps to ensure the physical safety of
The state requirement for Wisconsin hospitals is found at section HFS
- An adequate number of registered nurses shall be on duty at all
times to meet the nursing care needs of the patients. There shall be
qualified supervisory personnel for each service or unit to ensure
adequate patient care management.
The state requirement for freestanding psychiatric hospitals in
Wisconsin is found at section HFS 124.26(3)(a):
- The hospital shall have enough staff with appropriate qualifications
to carry out an active program of psychiatric treatment for
individuals who are furnished services in the facility [emphasis
Relevant federal requirements for hospitals participating in the
Medicare program include:
Although hospitals accredited by the Joint Commission on the
Accreditation of Healthcare Organizations (JCAHO) are deemed to meet
Medicare standards, they are not exempt from federal and state
Law enforcement or security personnel should not routinely possess
weaponry in psychiatric treatment areas. The hospital is expected to work
with law enforcement authorities in the community to develop alternatives
to law enforcement personnel retaining their weapons during routine
situations on a psychiatric unit. Wherever possible, psychiatric patients
should be removed from areas where law enforcement personnel are
performing official activities such as investigating crime scenes on a
patient care unit.
Occasional disruptive or aggressive behavior by psychiatric patients
against other patients, themselves, staff, or visitors should be
anticipated and planned for. Hospitals must develop policies and
procedures for the management of these special incidents. If this involves
using security staff or behavioral response teams that include
non-psychiatric unit staff for rare circumstances of unusual and
significant threats of harm, these personnel should receive training in
team stabilization and appropriate restraint methods.
The presence of weaponry on a psychiatric unit poses potential hazards
to patients, both physically and psychologically. Healthcare security
personnel who are assigned to work within psychiatric treatment areas may
not routinely carry weapons. While it is recognized that security or law
enforcement personnel who respond to rare incidents that are beyond the
control of psychiatric unit staff may initially be armed, it is expected
that officers will be asked to secure their weapons as soon as it is safe
to do so. Weapons should be secured after an initial threat assessment
(off unit when possible) determines that weapons are not needed, or as
soon after control of a violent individual is established.
Law enforcement personnel should not be expected to deal with
psychiatric patient management on the treatment unit. Use of armed
security or law enforcement personnel should be limited to emergencies
that are beyond the control of hospital staff.
When possible, teams comprised of healthcare staff, security (and/or
police officers) should train together periodically to prepare for such
emergencies using team stabilization methods. These methods should be used
(instead of weapons), whenever possible, during emergencies that exceed
the capability of the hospital staff.
Although the use of pepper agents and electric restraint devices are
commonly considered safe methods for subduing individuals, special care
must be exercised when subduing persons with health care needs.
Psychiatric patients are much more likely than the general population to
be taking prescription medications, and may have additional medical
problems, including, but not limited to, asthma, epilepsy, lung
conditions, or heart conditions. Some patients may be under the influence
of drugs when they are admitted, and female patients may be pregnant. The
hospital must make security or law enforcement officers who respond to
incidents involving psychiatric patients aware that there is a potential
for unintended harm to especially vulnerable patients.
All hospitals must have adequate policies and procedures to meet
applicable state and federal regulations to ensure a safe environment for
the specialized needs of patients as well as staff.
- Hospitals are encouraged to develop a written agreement with local
law enforcement personnel to address the issue of weapons on
- Hospitals may want to offer a lock box that is secured by the law
enforcement officer for the storage of firearms, electric restraint
devices, pepper agents, or other weaponry devices when an officer's
presence is necessary on a psychiatric unit. If officers do choose to
retain their weapons, the hospital should attempt to minimize any
safety risks to patients.
- Where possible, hospitals are encouraged to offer a secure, off-unit
area for law enforcement personnel to use in meeting with a patient in
an official capacity. In these situations, the hospital should provide
staff to accompany the patient during interviews with police officers.
- Hospitals may want to provide a double-door arrangement
outside of the psychiatric unit, or another designated place, to
exchange the custody of patients so that law enforcement personnel
would not need to enter an unsecured treatment unit or relinquish
- Hospitals should not use law enforcement personnel to remedy a lack
of adequate staff to manage patient behavior on psychiatric units.
- Hospitals should provide all staff with training regarding the
Federal Conditions of Participation for Patient Rights, especially
those rights regarding the use of restraint or seclusion. An excerpt
from the Interpretive Guideline relating to the use of restraints
under 42 CFR 482.13(f) is included on page 2 of this memorandum.
- Psychiatric staff, behavioral response teams, and security staff
should be trained in team tactic stabilization.
Psychiatric unit policies and procedures, adequate staffing levels,
including backup staffing, and effective training of staff to safely
de-escalate and contain problem situations, are essential elements of
effective inpatient psychiatric treatment. The use of security staff
(contract or internal) is not a substitute for qualified patient care
The routine presence of weaponry, including firearms, pepper agents and
electric restraint devices, even in the possession of a trained law
enforcement or security officer, is not an acceptable situation in
psychiatric treatment areas. Hospitals that are out of compliance with
state and federal regulations are encouraged to develop policies and
procedures and to implement necessary changes. Changes may be indicated in
physical environment, staff training in both verbal de-escalation and
alternatives to restraint or seclusion, training of hospital security
staff (employee or contract) in patient rights, protective equipment for
staff, cross-training other hospital staff in safe restraint techniques as
back-up, and/or quality assurance studies to identify staffing needs and
times of increased risk.
Law enforcement representatives have informed the Bureau of Quality
Assurance that enforcement personnel prefer not to be used to address
routine behavioral management issues on psychiatric treatment units due to
the specialized needs of the patient population. A cooperative working
relationship with local law enforcement is one of the many tasks hospitals
must undertake to assure the welfare and safety of patients being treated
for mental illness or substance abuse. Each hospital remains responsible
for working with the unique reality of their particular service area and
Please share this information with appropriate staff. You are welcome
to contact the Health Services Section at (608) 243-2024 or Helen
Brewster, ACSW, at (608) 243-2089 or firstname.lastname@example.org,
to discuss any aspect of this matter. A law enforcement resource is
Captain Steven Rogers, University of Wisconsin-Madison Police, at (608)
265-2598 or email@example.com.
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